Retinal Imaging Conference

Shivani V. Reddy, MDUniversity of Louisville

Department of Ophthalmology and Visual Sciences

6/5/2014

Patient Presentation

CC: Blurry vision OS x 1month

HPI: 52 y/o AAF presenting to the eye clinic for her first diabetic exam c/o occasional blurry vision OS x 1 month. Denies flashes, floaters, scotomas or episodes of vision loss.

Medical HistoryPOHx: none

PMH: DMII (diagnosed 3 months prior, A1c: 8.9%)

HTN with HTN urgency episode in 2012

secondary to cocaine abuse

Meds: metformin, lantus insulin, norvasc, gabapentin

Allergies: NKDA

Exam

BCVA P TTP

EOM: Full OU CVF: Full OU

Anterior Segment: mild NS cataracts OU, otherwise WNL

20/20-1 (sc) 3 ->2mm

3 ->2mm

14

17(-) RAPD

20/60-2 (-1.00+1.00x180)

OCT Photos

OCT OD

OS

OS: retinal thickening with cystic spaces temporal to fovea, subfoveal disruption of ELM and ellipsoid region lines

Autofluorescence OS

OD: Area of central hyperautofluorescence , hypoautofluorescense concentrated superiorly

FA Photo OS 00:19:53

Arterial phase : normal arterial filling

FA Photo OS 00:23:28

Mid AV phase : delayed superotemporal venous arcade filling, scattered areas of hypofluorescence, pinpoint hyperfluorescent areas

FA Photo OS 00:30:33

Late AV phase: persistent filling defect in superior temporal arcade, prominent macular collateral vessel, hypofluoresent ares scattered throughout the sup-temp segment

FA Photo OS 00:38:65

Venous Phase: Late filling of superotemporal venous arcade, increasing hyperfluorescence surrounding original pinpoint areas with persistent intervening hypofluorescent regions, hyperfluorescence temporal to the fovea, appearance of venous collaterals

FA Photo OS

Recirculation phase: increasing hyperfluoresnce around pinpoint leakages, decreasing fluorescence of collateral vessels. Increasing hyperfluorescence temporal and superior to the fovea

01:44:39

FA Photo OS

02:24:13 02:39:10

Assessment and Plan

A: 52 yo AAF with CME OS secondary to old branch retinal vein occlusion.

P: Avastin OS, follow-up pending

Branch Retinal Vein Occlusion

Vein occlusion that occurs most commonly at an AV crossing

Mean age of presentation: 7th decade

Risk factors HTN Cardiovascular disease Glaucoma history Increased BMI at age 20

Most commonly effected area: supero-temporal quadrant

Acute Phase Segmental intraretinal hemorrhage with apex

near obstructed vein Subretinal hemorrhages less common Cotton wool spots scattered throughout the

occluded segment CME with layering intraretinal heme within

the cysts If CME present, round yellow spot can occur

centrally that later disappears

Branch Retinal Vein Occlusion

Chronic Phase Resolution of subretinal heme at 9-12

months Underlying retinal vascular

abnormalities seen on FA Collateral vessel formation around blockage

site Capillary telangiectasia Capillary non-perfusion areas within

involved segment

Branch Retinal Vein Occlusion

Branch Retinal Vein Occlusion

Branch Vein Occlusion Study (BVOS)

Questions asked: Can scatter laser prevent neovascularization? Can peripheral scatter laser prevent vitreous

hemorrhage?. Can grid laser improve visual acuity in eyes with

macular edema with vision <20/40?

Conclusions: Grid laser is beneficial for macular edema with

vision <20/40 for 3 months Scatter laser is beneficial for prevention of vitreous

hemorrhage The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282. 2001;21:416-434.

Branch Retinal Vein Occlusion

SCORE (BRVO) Study Question asked:

Is triamcinolone beneficial in the treatment of macular edema when compared to standard of care?

Patients were divided into 3 groups: grid laser, 4mg , 1mg group. Visual acuity changes were compared at 1 year

Conclusions: 3 groups with similar VA improvement BUT more complications

in the steroid group. Therefore, Grid laser was the benchmark against which future treatments should be compared

Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128.

Branch Retinal Vein OcclusionBRAVO Study

Purpose: to determine the safety and efficacy of Lucentis in treating macular edema

Design: 3 groups – 0.3mg , 0.5mg ranibizumab and sham Patients received monthly injections

Number of patients with >15 letters gained at 6 months:

0.5mg group: 61.1%, 0.3mg group: 55.2%, sham group: 28.8%

Conclusion: Intravitreal ranibizumab is effective for treatment of macular edema following BRVO

Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.

Branch Retinal Vein Occlusion

GENEVA Study

Purpose: to evaluate the efficacy and safety of Ozurdex for visual loss secondary to macular edema associated with BRVO

Design: patient injected with intravitreal implant 0.7mg, 0.35mg or sham

Conclusion: Dexamethasone intravitreal implant can reduce the risk of vision loss and improve speed and incidence of visual improvement

Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24.

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, Fondazione GB Bietti, Roma Maurizio ParodiMacula Society, 2014

Purpose: to evaluate the effects of dexamethsone implant for the treatment of macular edema secondary to ischemic retinal vein occlusions over a 12 month follow-up

Methods: - prospective, open-label, interventional, case series. - each patient received a comprehensive exam, FA & OCT imaging followed by

a dexamethasone implant - retreatment based on presence of macular edema at month 4

primary outcome measure: ETDRS letter score secondary outcome measure: CME, number of injections during followup

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, Fondazione GB Bietti, Roma Maurizio ParodiMacula Society 2014

Results: 24 patients enrolled (11 CRVO, 13 BRVO) - mean ETDRS letter score changed:

BRVO 75,3 to 95,6 CRVO 44,3 to 60,8 - CMT change BRVO 544um to 321um CRVO 776um to 444um - mean #injections

BRVO: 1.7 CRVO: 1.8

Conclusions: Dexamethasone implant reduces ME in eyes with ischemic RVO’s, leading to a slight visual acuity improvement

The OMAR study: Comparison of Ozurdex and Triamcinolone Acetonide for Refractory Cystoid Macular Edema in Retinal Vein OcclusionAhmet Ozkok, M.D.,*Omar A Saleh, M.D.,* Douglas K. Sigford, M.D.James W Heroman, M.D. Shlomit Schaal, M.D., Ph.D.

Purpose: To compare the risks and benefits of adding either intravitreal dexamethasone implant (DEX) or preservative free triamcinolone acetonide (TA) to bevacizumab monotherapy in refractory CME due to RVO

Design: interventional, comparative study of 74 patients received bevacizumab, then later DEX (35) and TA (39) outcome measures: BCVA, CMT, frequency of injections

Results: no significant change in BCVA significant improvement in CMT

significant decrease in number of injections per month, more so in DEX group (from 0.66 to 0.26 inj/mo)

ReferencesRetina-Vitreous Macula. Guyer, Yannuzzi, Chang, Shields, Green

BCSC. Chapter 12 Retina and Vitreous. 2012-2013:Chapter 6:121-127.

The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282. 2001;21:416-434.

Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128.

Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24.

Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.

The Eye Disease Case-control Study Group. Risk factors for branch retinal vein occlusion. Am J Ophthalmol 1993;116(3):286-96.

Thank You